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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315920040
Report Date: 08/06/2025
Date Signed: 08/06/2025 12:28:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2025 and conducted by Evaluator Todd Tryon
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20250414122356
FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:ALEXIS THACKERFACILITY TYPE:
740
ADDRESS:3265 BLUE OAKS DRIVETELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: 47DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not dispense medication to residents as prescribed.
Staff did not refill residents’ medication prescriptions in a timely manner.
INVESTIGATION FINDINGS:
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On 8/6/2025 LPA Tryon and LPM Ordonez visited the facility to complete the complaint. LPAs met by phone with Alyssa Sellers covering Executive Director.
LPA has interviewed staff, reviewed facility documents and records.
Regarding the allegation that staff did not dispense medication to residents as prescribed, LPA has interviewed 4 involved staff and reviewed records. LPA learned that a new medication administration computer system was initiated in about January 2025. In the process of switching from the old to the new system, there were some "glitches" and issues; apparently not all the information transferred correctly, some dropped, etc. From interviews it appears that staff did the best they could with trying to keep up with the medications, used a combination of systems until it got straightened out, etc. Opionions seemed to differ somewhat between staff interviewed as to whether medicatons were given correctly, there were issues between various staff, etc. At this time, LPA is not able to ascertain if some medications did or did not get dispensed; allegation is UNSUBSTANTIATED.
(continued)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20250414122356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 315920040
VISIT DATE: 08/06/2025
NARRATIVE
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Regarding the allegation that Staff did not refill residents’ medication prescriptions in a timely manner. LPA has interviewed 4 involved staff, reviewed facility records. Some staff related that orders were turned in to the pharmacy by med techs timely, but then they did not get filled, and sometimes multiple requests were made, sometimes causing medications to be late. There were apparently differing opinions regarding whether staff were well-trained regarding medications, re-ordering and so forth. At this point, LPA is not able to come to a conclusion regarding the allegation, as there are several differing opinions about issues, "blame", etc. Allegation is UNSUBSTANTIATED.

A finding that an allegation is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation is occurred.

.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2025 and conducted by Evaluator Todd Tryon
COMPLAINT CONTROL NUMBER: 59-AS-20250414122356

FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:ALEXIS THACKERFACILITY TYPE:
740
ADDRESS:3265 BLUE OAKS DRIVETELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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2
3
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9
Staff did not ensure residents’ showering needs were met.
INVESTIGATION FINDINGS:
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Regarding the allegation that Staff did not ensure residents’ showering needs were met:
LPA has interviewed 4 staff, reviewed shower logs. LPA learned that one particular staff is pretty much able to convince resident R1 to shower at least 2 times per week, even though other staff do have trouble getting R1 to shower. Therefore, since the one staff is getting R1 to shower on a fairly regular basis, the allegation is UNFOUNDED.

A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Appeal rights provided, exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Todd Tryon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3